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tv   Craig Melvin Reports  MSNBC  April 12, 2021 8:00am-9:00am PDT

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hospital, taking care of basically the sickest heart disease patients in the hospital. and i also oversee their care in the intensive care unit. the second part of my clinical duties is i see patients in the outpatient setting, in the office, in the clinic. i evaluate, diagnose and treat patients. close to 50% of the patients, the new ones i see in the clinic, are referred by other cardiologists because these patients can sometimes have pretty complex medical conditions. then the third part of my clinical work is i perform procedures in a procedural suite we call the cath lab where i measure pressures inside the heart and inside the lungs. sometimes i will also take small biopsy samples of the inner lining of the heart for diagnostic purposes. >> given that you deal with a
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number of patients who could be really sick, do you ever have patients who pass away? >> so i work with a tremendous team at northwestern, and my colleagues save countless lives. unfortunately, many patients do die. >> do you ever have any involvement in determining the cause of death? >> oh, yes, i do. >> could you explain? >> sure. one of the most important parts of my job, in fact, is to determine what's wrong with a patient, including if they do actually die, how did they die? so there are a number of ways in which i participate in that role of figuring out what happened to a patient, how did they die. >> are you involved in any hospital committees that have as their purpose determining the cause of why people die or pass away?
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>> sure, i do. outside of being in the trenches, taking care of the patients at the bedside and figuring out what's going on trying to discern what might have happened, i also participate on a committee that meets regularly. what we do is we review all the cases in the cardiac intensive care unit. we look at any near deaths and any deaths. and we review looking at the medical chart and all of the evidence to try to figure out what might have happened for quality purposes to figure out if there was something else we could have done and also to improve our overall knowledge of the field. >> do you have experience with patients who sometimes pass away during what's called clinical trials? >> yes. i also participate in clinical trials where we try to determine if a certain medication or a certain device is worthy of being approved to help patients. in the course of clinical trials, sometimes there are deaths. in my role, i have sat on
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committees and our purpose on that committee is to review any deaths that do occur, look at all of the evidence to figure out, number one, why did the death happen and, number two, sometimes this is one of the more important parts to distinguish, was it a cardiac cause or was it for a reason that is not related to the heart. >> bringing this further home to this case, do you have experience with cardiac patients who die from what we call low oxygen? >> most certainly, i do. >> could you tell us about that? >> yeah. because i am a cardiologist who takes care of patients in the intensive care unit, having low oxygen levels is not uncommon. a lot of different disease processes can cause it. low oxygen levels can be very detrimental. some of our patients require ventilators and respirators. so in the course of caring for these patients, sometimes they
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succumb to their illness because their body is not able to get enough oxygen. >> do you ever have to determine cause of death in the heart transplant context? >> yes. in the field of heart transportation, what happens is when you get a phone call that somebody has died and they want to be an organ donor, what i need to do is look at the case from afar but try to look at all the rort records as closely as possible to sort out how that individual died and if there's any issues related to their heart or other parts of their body to make absolutely sure that that heart would be a good match for my patient who we are trying to help. so that's another element where you have to be really meticulous as you go through. you don't want to miss anything.
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the stakes are way too high. >> we heard from a pathologists. does your job require to you work with pathologists? >> yes. >> in what way? >> i work with cardiac pathologists pretty closely, perhaps more so than other general cardiologists. i take biopsy specimens and i send those to the pathologist to review. we participate in conferences that include reviewing autopsies. one of the things that i have learned over the years -- and i have been taught this by cardiac pathologists -- is that while a pathologist can look under the microscope and give us important information, i work with a world renounced cardiac pathologist who reminds me, please tell me as much clinical information as you can, put it in clinical
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context, because how i diagnose and interpret what i see under the microscope is very much influenced by the clinical story. so we work very closely together. because my pathologist looks under the microscope and actually sees the tissue at that level, and i can provide all of the clinical information, the time line, so we can truly get it right. >> a little bit more background, dr. rich. have you published in the field of cardiology? >> yes, i have. >> can you generally characterize what kinds of publications and how many? >> sure. to date, i've published more than 200 combined abstract, original manuscripts and book chapters. the topics have been pretty wide ranging in the field of cardiology from coronary artery disease, hypertension, which is high blood pressure, congestive heart failure and another disease actually called pulmonary hypertension. >> what is pulmonary hypertension? >> pulmonary hypertension is
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high pressures that are specific to the blood vessels in the lungs. when you blood flows from the heart to the lungs, if the pressure is high in those blood vessels, we refer to that as pulmonary hypertension. >> doctor, would you generally describe for the jurors, what is cardiology as a science? >> sure. cardiology is the study of the heart, the most basic level. it's the study of how the heart functions. what happens when the heart develops disease. pretty much everything heart related and how it interacts with the rest of the body in order to sustain life. >> how do you go about assessing a patient with a cardiology issue? >> sure. when you assess any patient with or without a cardiologist, but in this context, a cardiology issue, you typically begin by meeting the individual in the
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office, taking a history, doing a detailed physical examination, reviewing all of the medical records and the charts, looking at past procedures and tests they may have had. sometimes speaking to other colleagues who you are caring for that patient with together. then sometimes ordering your own tests for evaluation and diagnostic purposes. >> are some of your patients referred then from other cardiologists? >> yes. because of my specialty in advanced heart disease, close to half the patients who are -- i'm seeing in the office as new patients have been referred to me by other cardiologists typically in the community or in the region. i will assist them in consultation to figure out what's going on and what we need to do to help that individual. >> in the icu, do you take your patients who have problems beyond the heart? >> yes. it's interesting.
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as a cardiologist, i think part of the important reasons why they require of us to do that internal medicine residency training is because no organs work in isolation. so my patients who have heart disease who also require the intensive care unit, they will usually have issues with many other organs, lungs, kidneys, sometimes their brain. their liver. you really have to be adept and have a really good understanding of not just the heart but all of the organs of the body and really how they interact. >> dr. rich, let's talk about your role in this litigation. how did you come to be involved in this case? >> i was contacted by the state of minnesota. and i was asked as a cardiologist if i could review the facts of this case to help determine how mr. george floyd died. >> you have have you been comper
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the bulk of the work you have done on this case? >> up until my time here now at trial, i have not received compensation. >> why not? >> well, probably for a couple of reasons. mostly, i felt that my job as a cardiologist could really help inform the facts of this case. every year i take on a number of professional activities without compensation. i actually think it's a duty of our field. so in this case i felt i could make a meaningful contribution to the medical field. >> for your -- the compensation for your time while you are here at trial, are you being compensated at $1,200 per day? >> yes, $1,200 a day while i'm missing work back at home. >> let's talk about then your opinion or opinions in this case. before we do, could you tell us what work you did, what did you review before forming opinions in the case? >> sure.
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i was provided with a lot of evidence to look through. mostly, i looked through the medical records, interviews, all of the videos that were provided to me and the autopsy report. >> did you review some journal articles as well? >> yeah. as i was formulating my opinion and creating my expert report, i also looked up journal articles and embedded them into my report for references. >> have you formed any opinions in this case to a reasonable degree of medical certainty as to the cause of mr. floyd's death? >> yes, i have. >> would you tell us your opinion or opinions? >> sure. in this case, mr. george floyd died from a cardiopulmonary arrest. it was caused by low oxygen levels. those low oxygen levels were induced by the prone restraint and positional asphyxiation that
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he was subjected to. let's discuss your opinion, dr. rich. let's start with just a general discussion of the circulatory system and the heart. i'd like to talk about the right side of the heart, left side of the heart and also the alveoli. would you start off and just tell the jury, remind them, what are the alveoli? >> sure. you might remember hearing about this. but the alveoli are the grape-like structures that are at the very bottoms of the lungs. the alveoli is where the actual gas exchange occurs, meaning, that is where when we take a breath in, oxygen gets across the lungs and into the bloodstream and then the carbon dioxide that needs to leave the body crosses the same barrier. that's how the carbon dioxide is removed. it's the alveoli of the lungs
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that serve that purpose. >> what does a heart do in the body? >> what does the heart do? the heart is the major pump, of course, of the body. the best way to think of the heart in my view is to actually think of it as two pumps. a right side and a left side. if we start with the right side of the heart, after all that blood got pumped to the body and is coming back to the heart, blood is always returned to the right side of the heart. it does not have much oxygen in it. it needs to get more oxygen. that right side of the heart, its job is singular. it is to pump blood to the lungs. to those alveoli. so the blood when it heads towards lungs, it can pick up the oxygen and it can deliver carbon dioxide and other acids and waste products to be expelled from the body. once that blood from the right side of the heart has picked up
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the oxygen that it needed, it sends it to the left side of the heart. the left side of the heart gets all the glory because it is what then pumps all of that oxygen and nutrient-rich blood to the entire body. meaning to the lungs, to the kidneys, to the brain, to our muscles, to deliver oxygen. every organ, every tissue of the body needs oxygen in order to function. once that process occurs, it repeats back to the right side and so forth. >> what happens if the lungs can't deliver sufficient oxygen to the heart, that is, if there's a low oxygen situation? >> well, the heart is only as good as the fuel that it's provided with. when that right side of the heart sends blood to the lungs and says, okay, can i have some oxygen, please, if there's no oxygen there, or not enough oxygen there, there is nothing the heart can do to extract more from the lungs.
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it has to take that deoxygenated blood, that blood does not have enough oxygen and pump it to the left side of the body. the left side of the body says, this is what i have, this is what i'm going to pump. what ends up happening is the lungs don't give enough oxygen to the body, the heart has to pump insufficiently oxygenated blood to the tissues of the body. that's when problems occur. >> returning to your opinion, cardiopulmonary arrest caused by low oxygen induced by positional asphyxia, what caused the low level of oxygen in the case of mr. george floyd? >> in his okay, it was the -- truly the prone restraint and positional restraints that led to his asphyxiation. in a nutshell, he was just simply unable using all of his
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muscles, his chest wall, what we call accessories muscles of respiration, extra muscles triggered, he was trying to get in enough oxygen. because he was unable to because of the position that he was subjected to, as we just discussed, the heart thus didn't have enough oxygen either, which then means the entire body is deprived of oxygen. >> low oxygen induced by positional asphyxia. did you consider other possible causes of mr. floyd's death? >> sure. i tried, of course, to be as thorough as possible. but i focused mostly on two other potential causes, number one, is whether there could have been a primary heart contribution to george floyd's death. and the second was whether a drug overdose could have caused his death. >> doctor, would you tell the jury, what is a primary heart
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event? >> sure. a lot of things can jury the heart. for example, if you do not take in enough oxygen, that will jury all of the organs, including the heart. when i use the term a primary heart event, i mean something that original to originated fro heart itself. for example, a heart attack. one of the arteries got blocked completely and a heart attack occurred. or the heart just, without any explanation, nothing elseduing o a chaotic rhythm on its own. if any of those things happened, then i would consider that a primary heart issue not being caused or secondary to something else.
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>> you considered whether or not mr. floyd might have passed away from a primary heart event or a drug overdose. did you reach an opinion or conclusion to a reasonable degree of medical certainty as to whether either of those two causes explained mr. floyd's death? >> yes, i did. >> would you tell us your opinion? >> sure. after reviewing all of the facts and evidence of the case, i can state with a high degree of medical certainty that george floyd did not die from a primary cardiac event, and he did not die from a drug overdose. >> thank you, dr. rich. would you tell us, what evidence or facts, documents, what did you look at to help you to reach that conclusion about primary heart event and/or drug overdose? >> sure. the three aspects of the evidence that i spent the most time reviewing were mr. george floyd's medical records, the
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videos, the different angles from the day that he died on may 25th, 2020, and the autopsy report. >> the medical records, the videos and then the autopsy report? >> yes. >> let's start with the medical records then of those three. would you tell the jury what you were looking for in the medical records? >> sure. you get the medical records. it's usually pretty thick. you take it one page at a time. at the outset, i was looking to see if he had been diagnosed with any medical conditions. that's the first step. it's what you do with a patient in the office. what medical problems do you have? i was looking to see initially what diagnoses george floyd may have previously been diagnosed with. >> what were your takeaways from having looked at the medical records and done this assessment? >> at that level, i felt pretty
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confident that mr. floyd had three medical problems. number one, he had hypertension, high blood pressure. number two, it appeared to me that he may have suffered from anxiety. three, it looked like he also struggled with substance abuse. >> other than those three conditions, did mr. floyd have any diagnosis of heart disease while he was still alive? >> no, he did not. >> you said you looked at the medical records not only for diagnosing pre-existing conditions but also for evidence of medical encounters? >> correct. >> by that you mean hospital visits, clinics? >> emergency room visits, exactly. >> what did you find in that regard? >> so this is in my opinion was a really important part of the review as well. every time mr. floyd had an
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encounter with a medical professional, i viewed that as an opportunity to see if there was any signs, symptoms whatsoever, even subtle, that could have indicated, for example, that he had anything going on with his heart. at the emergency room visits, he had one prolonged hospitalization, i really tried to take a look at everything. i looked at any opportunity i could see if he ever complained of chest pain, which he did not, palpitations, a flu fluttering sensation of thephysical examine if there with respect any abnormalities. nothing found. i liked at all of the labs to see if there were any cardiac markers. i reviewed ekg and other tests. i tried to be as thorough as possible, because i viewed this
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as -- i view what we do as a clinician as some ways being a bit of a detective. our job is to try to figure out what might be going on, even if it's not overtly stated so in the chart. >> would you tell the jury, by the way, what an ekg is? it's shorthand for an electrocardiogram. they put sticky things on the chest. we electrodes. it's an opportunity after the surface level of the chest, it can give you a glimpse into the heart itself to see a whole host of things, including, is there any evidence of any heart injury happening now or previously, any abnormal heart rhythms, a whole host of other information that we can get from the ekg at that snapshot in time. then sometimes what we will do is repeat ekgs down the line so
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we can compare and contrast and see if anything had changed. >> you looked at all of this medical information on mr. floyd, including the ekg. did you note any cardiac problems that related to mr. floyd? >> i noted no cardiac problems in the medical records as far as mr. floyd's medical condition was concerned, including everything i mentioned, ekg, even a time where they put him on a continuous cardiac telemetry monitor, which they will do sometimes to see beat to beat if anything is going on. i reviewed that as well. >> did you see any evidence of mr. floyd having had any abnormal heart rhythms? >> his ekg showed absolutely no abnormal heart rhythms. he had that cardiac telemetry i mentioned that he had on for a few days. did have on rare occasion something you would call a pvc, which is a very normal finding.
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i don't know if anyone felt their carotid flutter for a second. it happens to all of us. absolutely no arrhythmias for the duration of the time he was on the monitor. >> pvc is not a plastic pipe. you mean -- >> premature ventricular contraction. people referred to it as a skipped beat. a normal phenomenon if you drink coffee, sleep deprived. it's common for us to have those. totally normal finding. something that none of you should be concerned about if you feel that from time to time. >> did you find any evidence that mr. floyd had any negative heart conditions? >> there was absolutely no evidence to suggest that at all. >> dr. rich, isn't high blood pressure an abnormal heart condition? >> thank you for that question. because i think that's an area of confusion sometimes.
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high blood pressure in and of itself is not a heart condition. high blood pressure occurs for basically two reasons. number one, high blood pressure originates in the blood vessels of our bodies. often it's genetically determined. if you have a strong heart, you can also generate high blood pressure. so those two in combination. i will pause there and can explain more. >> did mr. floyd have a strong heart? >> every indicator is that mr. floyd had actually an exceptionally strong heart. he was able to generate pressures of upwards of 200 millimeters of mercury on some occasions. we talked earlier about my role as a heart transplant cardiologist. one of the problems with patients when they need a heart transplant is the opposite.
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their hearts are so weak they can't generate a high blood pressure. their top number might just be 80. the reason why high blood pressure though is important -- and it is important to treat high blood pressure -- is because over time, if high blood pressure goes untreated, 10, 20, 30 years, the impact of that high pressure on the heart can eventually start to become a bit of a problem. the way i explain it to my patients who come into the office and i talk to them about treating their high blood pressure is i say, remember, the heart is a muscle. if you go to the gym and you pick up a couple of dumbbells and you start to lift the weights, initially it feels fine. in fact, you probably get a little stronger. your muscle will likely get even a little thicker, a little bigger, which is what it is supposed to do. initially, that might actually be a really good thing.
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if i came back ten years later and said, how is it going? you would say, this getting tough. then the muscle can start to tire out. we do want to treat high blood pressure. i can't emphasize that enough. high blood pressure should be treated. high blood pressure in and of itself is not a heart condition. >> we talked about your review of the medical records. you also looked at video footage in forming your opinions. would you tell us what you were looking for in the video footage that you examined? >> sure. my approach to the video initially was similar to my approach of the medical records. meaning, i wanted to just do cursory inspection, observation, basic stuff. what did mr. floyd look like? was mr. floyd talking? if he was talking, was he talking clearly, coherently,
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answering questions appropriately? did i notice any evidence of abnormal physical exams on the video, actually, i was trying to look for as well? when mr. floyd was walking, did he appear like he was walking without difficulty, or was it looking like he was perhaps with low blood pressure and maybe going to fall down? i was listening for any opportunity i could to hear he might say i'm having chest pains or fluttering sensations, what i do when i assess any person for a possible medical problem. i was looking for any and all of those possible subtle signs. >> this is video footage from mr. floyd's encounter on may 25th of last year? >> may 25th, that's correct. >> were you focused on things that would give you any insight into his ability to brother? >> yes, of course. >> the ability to expand what is
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referred to as his chest wall? >> yes. >> refresh the recollection of the jury. what is the chest wall? >> the chest wall, which i'm trying to sort of show you with my hands here, basically makes up the bones and the muscles of the entire rib cage. it might have been explained previously to you. but the chest wall and the muscles and how they interact, along with the diaphragm muscle inside, are the key structures that determine if someone is able to take in enough air and able to get enough out. if there is -- for example, the lungs can be working okay. but if the chest wall is diseased, if the muscles associated with the chest wall aren't able to contract and move and do their job, enough oxygen can't get in that way either. >> doctor, in our covid world,
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do you make clinical assessments of your patients in your work life by video? >> yes. actually, that is one of the transformations that we have needed to adapt to this past year. we are getting back to now seeing most of our patients in person. but during the course of this pandemic, to minimize exposures, we have set up a lot of these tele-video visits with patients. what i came to appreciate is that while there's no substitute to actually putting your hands on a patient, that is still preferable in my opinion to really examine them closely, you can get a lot of information off of a video assessment, even physical examination by looking at -- i have them turn their neck to the side. i can see their neck veins, which is an indicator of pressures. i can see their legs to see if there's any indication of swelling, which might be congestive heart failure. i can see the patient. i can see how they are
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breathing. i can hear how they are talking. if they seem breathless or short of breath. we actually have found out we can do a lot via video assessments. >> were you able to then see mr. floyd at the period of time after he was first approached by the police on may 25th, 2020? >> yes. >> what were your observations about mr. floyd from that initial encounter with the police? >> so, from his initial encounter, remembering particularly when he was asked to get out of his car, he appeared fear full but was speaking, i thought clearly, answering questions appropriately. didn't see any acute -- what we would call acute distress. i saw no indicators at that time that he was suffering from low oxygen, for example, or from any active medical problem. as i said, i was really trying to keep a close eye on some of the subtleties of his appearance
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and speech and so forth. >> were you able to observe at the point that he was being asked to get into the squad car? >> yes, i was. >> what were your observations with respect to that period of time? >> yeah. so i watched him walk to the squad car. then i was observing an interaction where they were asking him to get into the back seat of the car. i heard him talking about how he was claustrophobic. there were times where he was being -- i'm not sure if it was pushed into the car or how it was. even made indicators at that time that he couldn't breathe. all of my observations at that point were still that up until the point that he was kind of getting pushed or pulled through the car and ultimately on the pavement, up until that point, i also saw no evidence that there was anything active going on from a cardiac standpoint.
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that was really important for me to conclude. >> what sort of active thing might you have been looking for related to the heart over that period of time? >> yeah. so, for example, let's say he was having an arrhythmia, an abnormal heart rhythm, especially if it was originating from the heart. often, you will have the heart rhythm that goes abnormal. you will go from being totally fine, like hopefully we are all today, to instantly dizzy or passing out. i didn't see any indicators that was happening. i didn't hear him complaining of dizziness or fluttering of the chest. i couldn't see any swelling in his body. i didn't want to take anything for granted that even from the initial encounter up until that point, what if something developed from point a to point b? so again, up until that point, i saw no indicators of low blood pressure or anything else abnormal with the heart. >> turning then to the restraint
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on the ground that you were referring to, what were your observations then as a cardiologist from your having viewed mr. floyd's restraint on the ground by mr. chauvin? >> sure. my observations were that he was restrained in a life-threatening manner, specifically, my observations were that he was on the ground in the prone portion handcuffed, hands behind the back, a knee on the back of his neck, a knee on the back of his upper torso or shoulder, hands pushing his handcuffed hands further up into his chest. i observed a knee compressing his -- i thought it was his buttocks or upper thighs. then at various points his lower extremities being pinned down to the ground. my initial observation was, what
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is the position, first and foremost, that he is being subjected to? >> did you see at some point watching the video that mr. floyd went into cardiopulmonary arrest? >> eventually, yes, i did. >> do you know what mr. floyd's heart rhythm was when he was taken from the scene? >> well, so, in the course of the restraint, i was looking to see if his deterioration occurred rapidly, like i was just talking about, for example, a primary cardiac event, the most common arrhythmia is what we call ventricular fibrillation. when that happens, the individual will look relatively okay, meaning they are alert, they are talking, and then they
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will immediately become unconscious. on the other hand, if the cause of the cardiopulmonary arrest was from something else, for example, low oxygen levels, you will typically see that deterioration happening much more gradually and slowly. so my observations were the second. that you could see -- at least i could see his speech starting to become less forceful, his muscle movements becoming weaker, until, of course, eventually his speech became absent, eventually his muscle movements were absent and then as we later discovered by the heart rhythm, he was in a pea cardiopulmonary arrest. >> i would like to talk to you about two concepts. the one being pea.
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which pulseless electrical activity. and the other one being a thing called asystole. first, dr. rich, would you tell us what pulseless electrical activity is? >> sure. pulseless electrical activity or for short pea is a chaotic heart rhythm that you can see on the ekg or on the cardiac monitor. but there is an absence of a pulse. so it doesn't meet criteria for
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this asystole that i think we will talk about in a minute, or for ventricular fibrillation. if i will use my fingers, is the heart rhythm looking like this. it's this little subtle fluttering but basically nothing else going on. pulseless electrical activity, if you are a clinician, a doctor or a nurse or anyone, for that matter, who has ever been trained in cardiac arrest, one of the things that will come to mind immediately is whenever you see a pea arrest, you need to think about what's causing it. nearly all pea arrests are being caused by something relatively specific. if you can identify what that is, it can be reversed. >> what is the most common cause of pea? >> you might have heard of others talking about the h and
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t. one of the h, the most common cause for a pea, cardiopulmonary arrest, is hypoxia, not enough oxygen levels. >> low oxygen? >> low oxygen. >> what about asystole? >> asystole is the flat line. when any human dies, they will eventually go into asystole where there will be absolutely no heart rhythm occurring, even this chaotic rhythm. that's sometimes called that flat line. pea can have a variety of chaotic looking rhythms without a pulse. asystole is the absence of any cardiac electrical activity.
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>> if mr. floyd is in a pea state or generally anyone, is pea reversible? >> it is important to put it into context. we see pea cardiac arrests in the hospital all the time. whenever you see a pea cardiac arrest, you rush to it, of course, and you begin the protocol. that protocol is the h and t. you give oxygen if you don't think they have enough oxygen. that's the most critical thing to do. depend on the other hs, for example, hemorrhage, if you think they are bleeding out from a trauma, you would give them blood. we are doing these things simultaneously, because time is of the essence. we resuscitate patients with cardiopulmonary arrest from pea not infrequently. unfortunately, pea can also be a devastating cardiac arrest and
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despite all of our best abilities, sometimes it's not reversible. >> dr. rich, did you see any evidence at all that george floyd had had a heart attack? >> no, none whatsoever. >> what about this notion of something called a silent heart attack? >> a silent heart attack? well, so a silent heart attack, you know -- a silent heart attack is sometimes referred if it looks like someone might have had a heart attack but there were no clinical signs to suggest it. it's a relatively uncommon finding. it tends to happen inpatients who have diabetes, because when you have diabetes, one of the problems is you lose sensation in the nerve endings. typically, when you are having a heart attack, see people clutch their chest, i'm having chest pain. sometimes diabetics won't have that.
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it's possible that they can have a silent heart attack. there was no evidence that mr. floyd had any type of heart attack, a silent heart attack or a non-silent heart attack. >> you talked about this a little bit, about the notion of a cardiac arrhythmia. the fluttering of the heart. i think you referred to it. was there any evidence that he had either of those? >> no, there was no evidence he had any of those. >> when somebody is suffering from ventricular fibrillation or tachycardia, did you describe that as a sudden death event? >> yes. ventricular fibrillation can cause sudden cardiac death. that absolutely could be described at that. >> in viewing mr. floyd and his
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encounter on the videos from may 25th, did mr. floyd die a sudden death? >> mr. floyd died a gradual death. it would not be considered the classic sudden death from the standpoint of how you are putting into that context, meaning when people have that ventricular fibrillation, that vf arrest, they literally go from being fine one moment to completely out the next. i don't know what happened. i was sitting next to him and he keeled over and was on ground. that could have been a vf arrest. sometimes there's semantics in terms of this. in the case of mr. floyd, yes, did he have a cardiopulmonary arrest. but, no, he did not -- there was no evidence of a sudden cardiac death from any malignant heart arrhythmia.
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>> we talked about your view of the medical records and we talked about your review of the video. the third thing you said you reviewed was the autopsy report and findings. >> yes. >> what were you looking for with respect to the autopsy report and findings? >> sure. we're talking about the autopsy report here towards the end. i actually looked at the autopsy report first. then i went back to the medical records that we have talked about and the videos. then i went back to the autopsy again. what i was looking for in the autopsy was -- first of all, everything. when we get an autopsy, often you will get it because you are looking, could there be something we weren't aware that was could have happened? in addition to looking at all of the findings, my major focus, of course, as a cardiologist was anything and everything related to the heart. >> what did you find? >> you know, it's interesting. i think what was most important was not only what i found but
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what i did not find. what i found was that his heart architecturally looked normal. he had a description of coronary artery disease, which i found notable, because as i mentioned before, he hadn't carried a diagnosis of coronary artery disease. i mention i found it notable. i certainly didn't find it unusual, because, unfortunately, coronary artery disease is so common. statistically, not to scare anybody, many of us in this room likely have coronary artery disease. i looked at whether there was any evidence whatsoever that mr. floyd could have had a heart attack based on autopsy. when i looked at those arteries around the heart, i not only looked to see how narrow they were and what the composition of that narrowing was, but also
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whether there were any platelets or clotting factors or anything else of that nature in the arteries, which is what would be there if there was a heart attack. >> did you see evidence of the platelets you expected to see if mr. floyd had had a heart attack? >> there were no description of any of the platelets or clotting factors or anything that would block off an artery. none of the arteries were totally -- the word we use is occluded, totally blocked off, which is what happens in a heart attack. >> i want to ask you about some of your specific findings in this regard. first, for the jury, would you tell them whether you excluded coronary artery disease as a cause for mr. floyd's death? >> yes, i have excluded that with a high degree of medical certainty. >> you talked about looking for evidence of platelets from the autopsy report and that you would expect to have seen those
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if he had died from a heart attack. you didn't see them. >> right. >> what else did you see? >> what i also saw was i looked at the heart muscle itself. not only did the heart muscle itself not show any evidence of any injury at all, which you would see -- you mentioned the silent heart attack. what if he had a mini-heart attack? you would see evidence of that in the heart. you would see scar tissue. not only did i not see any evidence of a heart attack, the pathologist did a very good job, in my opinion actually, of describing what's called the endocardium. it's the inner most lining of the heart. that is the most susceptible part of the heart to cardiac injury. even the smallest of heart attacks will always originate on that endocardium.
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it was not only described as normal, it was described as smooth and glistening. a completely normal finding. no evidence at all of even small microscopic injury. >> were you able by your looking at the autopsy report on the heart to tell whether there was any evidence as to whether mr. floyd had ever had a heart attack, even going back into the past? >> no evidence whatsoever of a previous heart attack. >> doctor, what is ischemia? >> ischemia is a reduction in blood flow to any organ of the body that could be the heart, the kidney, that can lead to basically insufficient delivery of oxygen for a short period of time. if ischemia continues to occur
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for long enough, that can sometimes cause an irritability in the organ. it's important to distinguish ischemia from infarct. infarct is a heart attack. when a marathon runner goes on a run, their muscles will get temporarily ischemia. when we lift in the gym, they talk about feeling the burn, that means you are feeling ischemia. you are feeling lactic acid build up. that's what ischemia is. >> any evidence of ischemia? >> not on the autopsy, no. >> let's talk about the blood vessels, the arteries and the plaque that was in the arteries. were you able then to eliminate the occlusions, the blockage in the arteries as a contributing cause to mr. floyd's death? >> yes. i would like to clarify. i saw no occlusions, meaning, i
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saw no complete blockages. there were narrowings. there were narrowings in more than one blood vessel. importantly, the main coronary artery, the left main coronary main coronary artery there was no description of any narrowings or disease in the left main coronary artery. >> why is that significant? >> well, because that is the first main pathway the blood travels to branch off into multiple other arteries. so left main disease as we sometimes call it in cardiology is among all of the vessels, probably the highest risk blood vessel if it were to get blocked off. >> so how would you characterize the nature of the plaque within the artery? was it soft? was it fractured? how would you characterize it? >> i would characterize it the way that the medical examiner
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characterized it. i'm not an expert at characterizing plaque at a microscopic detail, but what i did appreciate was the description of what seemed to be not only relatively conventional-looking artery narrowings, plaque buildup that we all will eventually get in our arteries. it was described that there was an element of calcium, and i only mention that because that also indicates that this coronary artery disease just didn't develop right away. it was probably a slow, gradual build up of the narrowings and that actually is a very clinically relevant finding in the field of cardiology. >> doctor, did you make any assessments around the size of mr. floyd's heart? >> yes, i did. >> would you tell the jury about that? >> sure. so when looking at the size of his heart, not just the size but
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the thickness of the heart, it was described as being mildly thick or mildly enlarged. now depending on which criteria you use, one criteria would agree with that, that it was mildly thick or enlarged. others would suggest that it was in the normal range. i do believe that it was mildly thick and mildly enlarged and it is an expected finding in someone that has high blood pressure and even though there are scoring systems that would say it wasn't enlarged at all, in my view as a cardiologist, i do believe there was just the smallest element of increased heart thickness and as i mentioned before, that's important because that's exactly what the heart is supposed to do when there's high blood pressure. that is a normal response.
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the muscles are getting stronger and it's allowing the heart to work and work well. now if that goes on for, like i said before, 20 years, we can have problem, but early on, having a mildly thickened heart is not only a normal finding in someone with high blood pressure, it may be beneficial in the short term? >> doctor, putting all of this together, did you see any evidence at all that the primary cause of mr. floyd's death originated in his heart? >> no, i did not. let's talk about i new subject, whether or not mr. floyd suffered from a drug overdose and died from a drug overdose. that was something that you also considered as a cause. >> yes, sir. >> are you familiar with mr. floyd's toxicology results. >> yes, i am. >> which substances did you consider in evaluating mr.
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floyd's toxicology history? >> when i looked at the toxicology reports i focused mostly on the finding of fentanyl as well as the finding of methamphetamines. >> what role, if any, do you feel that the fentanyl played in the cause of mr. floyd's death? >> as far as i can tell from reviewing all of the facts of the case i see no evidence at all to suggest that a fentanyl overdose caused mr. floyd's death. >> as a cardiologist, do you have to occasionally have to care for patients who struggle with opioids or opioid addiction? >> absolutely. >> so here, you found that the fentanyl, in your opinion, played no role in mr. floyd's death. would you tell us how it is that you hold that opinion? how do d you reach that conclusion?
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>> i would break it down to two major reasonings. number one, it appeared to me that mr. floyd, what was an acknowledged frequent, chronic user of substances, particularly opiates likely developed a high degree of tolerance. there's even one emergency room visit that i had reviewed where he came in and he told the emergency room team that, you know, he was tearful and says i'm having trouble with substance abuse and i think he said i took eight percocets in two hours and he had no side effects at all, they reviewed him for a couple of hours and they discharged him. he had built up a high tolerance to opiates and just as important, maybe more important, was i didn't see any of the signs of an opiate overdose when i reviewed the videos. >> and -- i'm referring to the signs of an opiate overdose,
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would you tell the jurors or describe for them what are those signs and what didn't you see? >> sure. so in my experience in the intensive care unit, taking care of patients who come in with an opiate overdose, first of all, they are extremely lethargic. often times nearly unarousable, and you try to wake them up and they're falling right back asleep. they're not talking to you. if they are talking to you they're often having slurred speech. if they're standing up which they wouldn't be which they have a fentanyl intoxication or an overdose, they would get pretty dizzy pretty quickly. i kind of saw all of the opposite with mr. floyd. i saw that he was alert. he was awake. he was conversant. he was walking, and according to the toxicology report, he had
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this degree of fentanyl in his system. so just looking at the clinical story i didn't see any signs or symptoms of fentanyl overdose. let's turn to methamphetamine, then. what role do you think that methamphetamine played in mr. floyd's cause of death? >> i feel it played no substantive role at all. >> why is that? >> all considering, it was very relatively low level of methamphetamine in his system and so when you look at the context of the case and you see relatively low level of methamphetamine in the context of everything else, i felt very confident that that degree of methamphetamine was not what was triggering this profound, cardiopulmonary arrest and ultimately p.e.a. arrest.
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>> taking into account in all of the evidence that you reviewed, do you have an opinion to a reasonable degree of medical certainty as to whether mr. floyd's death was preventable? >> yes, i do. >> would you tell us what that opinion is? >> yes. i believe that mr. george floyd's death was absolutely preventable. >> were there critical points in time during his subdural and restraint on the ground when you feel measures could have or should have been taken that would have preserved his life? >> yes, i do. i think there were several junctures, actually. >> would you tell us about those? >> of course. the first was to not subject him to that initial prone restraint positioning that he was subjected to. i mean, that is first and foremost. so if that was not the case, i don't think he would have died. the second, though, was when he
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was in that subdural and restrain positioning and he was stating repeatedly that he can't breathe and he was getting a little weaker in his speech. there was one moment in the video where i heard one of the officers saying "i think he's passing out," that would have been an opportunity to quickly relieve him from that position of not getting enough oxygen, perhaps turn him into a recovery position and allow him to start to expand his lungs again and bring in oxygen and get rid of carbon dioxide. so in addition to not putting him in that position in the first place when there were signs that he was worsening,
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repositioning him, i think very likely would have also saved his life. >> was there a point in time, dr. rich, when mr. floyd was checked for a pulse when he was in the subdual restraint of mr. chauvin? >> yes. yes, was there. >> at the time that he was checked for a pulse and he no longer had one, in your opinion as a cardiologist, was there anything mr. chauvin could have done at that point in time that would likely have saved mr. floyd's life? >> objection. >> sustained. >> at the time that mr. floyd did not have a pulse, what is your opinion to a reasonable degree of medical certainty as to what mr. chauvin would have dot

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